Tuula Vasankari

Towards tuberculosis elimination: an action framework for low-incidence countries

This paper describes an action framework for countries with low tuberculosis (TB) incidence (<100 TB cases per million population) that are striving for TB elimination. The framework sets out priority interventions required for these countries to progress first towards “pre-elimination” (<10 cases per million) and eventually the elimination of TB as a public health problem (less than one case per million). TB epidemiology in most low-incidence countries is characterised by a low rate of transmission in the general population, occasional outbreaks, a majority of TB cases generated from progression of latent TB infection (LTBI) rather than local transmission, concentration to certain vulnerable and hard-to-reach risk groups, and challenges posed by cross-border migration. Common health system challenges are that political commitment, funding, clinical expertise and general awareness of TB diminishes as TB incidence falls. The framework presents a tailored response to these challenges, grouped into eight priority action areas: 1) ensure political commitment, funding and stewardship for planning and essential services; 2) address the most vulnerable and hard-to-reach groups; 3) address special needs of migrants and cross-border issues; 4) undertake screening for active TB and LTBI in TB contacts and selected high-risk groups, and provide appropriate treatment; 5) optimise the prevention and care of drug-resistant TB; 6) ensure continued surveillance, programme monitoring and evaluation and case-based data management; 7) invest in research and new tools; and 8) support global TB prevention, care and control. The overall approach needs to be multisectorial, focusing on equitable access to high-quality diagnosis and care, and on addressing the social determinants of TB. Because of increasing globalisation and population mobility, the response needs to have both national and global dimensions. Action framework for countries with low tuberculosis incidence: a coherent approach for eliminating tuberculosis http://ow.ly/H03ZZ

The geographic diversity of nontuberculous mycobacteria isolated from pulmonary samples: an NTM-NET collaborative study

A significant knowledge gap exists concerning the geographical distribution of nontuberculous mycobacteria (NTM) isolation worldwide. To provide a snapshot of NTM species distribution, global partners in the NTM-Network European Trials Group (NET) framework (www.ntm-net.org), a branch of the Tuberculosis Network European Trials Group (TB-NET), provided identification results of the total number of patients in 2008 in whom NTM were isolated from pulmonary samples. From these data, we visualised the relative distribution of the different NTM found per continent and per country. We received species identification data for 20 182 patients, from 62 laboratories in 30 countries across six continents. 91 different NTM species were isolated. Mycobacterium avium complex (MAC) bacteria predominated in most countries, followed by M. gordonae and M. xenopi. Important differences in geographical distribution of MAC species as well as M. xenopi, M. kansasii and rapid-growing mycobacteria were observed. This snapshot demonstrates that the species distribution among NTM isolates from pulmonary specimens in the year 2008 differed by continent and differed by country within these continents. These differences in species distribution may partly determine the frequency and manifestations of pulmonary NTM disease in each geographical location. Species distribution among nontuberculous mycobacteria isolates from pulmonary specimens is geographically diverse http://ow.ly/npu6r

Risk factors for poor tuberculosis treatment outcome in Finland: a cohort study

BackgroundWe investigated the patient- and treatment-system dependent factors affecting treatment outcome in a two-year cohort of all treated culture-verified pulmonary tuberculosis (TB) cases to establish a basis for improving outcomes.MethodsMedical records of all cases in 1995 – 1996 were abstracted to assess outcome of treatment. Outcome was divided into three groups: favourable, death and other unfavourable. Predictors of unfavourable outcome were assessed in univariate and multivariate analysis.ResultsAmong 629 cases a favourable outcome was achieved in 441 (70.1%), 17.2% (108) died and other unfavourable outcome took place in 12.7% (80). Significant independent risk factors for death were male sex, high age, non-HIV -related immunosuppression and any other than a pulmonary specialty being responsible for stopping treatment. History of previous tuberculosis was inversely associated with the risk of death. For other unfavourable treatment outcomes, significant risk factors were pause(s) in treatment, treatment with INH+RIF+EMB/SM, and internal medicine specialty being responsible at the end of the treatment.ConclusionWe observed a significant association with unfavourable outcome for the specialty responsible for treatment being other than pulmonary, but not for the volume of cases, which has implications for system arrangements. Poor outcomes associated with immunosuppression and advanced age, with frequent comorbidity, stress a low threshold of suspicion, availability of rapid diagnostics, and early empiric treatment as probable approaches in attempting to improve treatment outcomes in countries with very low incidence of TB.

Effects of Acute Prolonged Exercise on Serum and LDL Oxidation and Antioxidant Defences

We investigated the acute effects of long-distance running on oxidation of lipids and antioxidant functions in LDL and serum. Eight trained male runners who participated in a 31-km run and 22 male keep-fit runners who participated in a marathon run were enrolled into the study. Venous blood samples were taken before and immediately after the exercise. There were no changes in LDL diene conjugation (LDL-DC) or LDL antioxidant potential (LDL-TRAP) during the exercises. Serum (S-) TRAP and S-alpha-tocopherol rose during the 31-km run (by 22%, p = .0005, and by 29%, p = .011, respectively), and during the marathon (by 16%, p = .0014, and by 7%, p = .031, respectively). S-DC rose during the 31-km run (by 9%, p = .0026), but not during the marathon (p = .14). Preexercise and postexercise S-alpha-tocopherol correlated positively with pre and postexercise S-TRAP in the marathon run (r = .473, 95% CI 0.064 to 0.746, and r = .524, 95% CI 0.131 to 0.774, respectively). Thus, the paradoxical exercise-associated increase in S-TRAP is, at least in part, explained by a simultaneous rise in S-alpha-tocopherol concentration. However, acute exercise does not change LDL-DC or LDL-TRAP concentrations.

Chlamydia pneumoniae and Severity of Asthma

A substantial increase in the prevalence of asthma in the Western world during the last few decades has led to a continuous search for novel factors that might be involved in the development of the disease. We carried out a study to clarify whether there is a relationship between severity of asthma and Chlamydia pneumoniae-specific titres at the group level and whether antibodies to the 60 kDa chlamydial heat shock protein (chsp60) are associated with asthma. A total of 116 (31 men, 85 women) consecutive asthma patients from a chest clinic were recruited and divided into 3 groups according to the severity of the disease: there were 13 asthmatics with severe, 54 with moderate and 49 with mild asthma. In addition, 50 (31 men, 19 women) consecutive blood donors were enrolled to serve as a control group. Sera for the measurements of specific IgG, IgA and IgM antibodies using a microimmunofluorescence test and of chsp60 using an enzyme immunoassay were obtained upon enrolment and also 3-4 months later from the asthma patients. Severe and moderate asthma were found to be strongly associated with elevated IgA antibody levels to C. pneumoniae [odds ratio (OR) 5.58, 95% confidence interval (CI) 1.31-23.72 for severe and OR 5.65, 95% CI 2.05-15.53 for moderate asthma] in a logistic regression model. Furthermore, in women, the occurrence of elevated IgA antibody levels and the age-adjusted geometric mean titres of IgA antibodies were significantly higher among the asthmatics than the controls (p=0.003 and 0.04, respectively). Antibodies to chsp60 occurred more frequently and in higher concentrations among the asthmatics than the controls, although the differences did not reach significance. In conclusion, severe and moderate asthma were significantly associated with elevated IgA antibody levels to C. pneumoniae suggestive of chronic infection. Antibodies to chsp60 did not prove to be a useful marker of such an infection among the asthmatics studied here.

The 10-year COPD Programme in Finland: effects on quality of diagnosis, smoking, prevalence, hospital admissions and mortality.

BACKGROUND The Finnish National Programme for Chronic Bronchitis and Chronic Obstructive Pulmonary Disease (COPD) 1998-2007 was set up to reduce the prevalence of COPD, improve COPD diagnosis and care, reduce the number of moderate to severe cases of the disease, and reduce hospitalisations and treatment costs due to COPD. Over 900 events for 25,000 participating healthcare workers were arranged. The major strengths of this programme included multidisciplinary strategies and web-based guidelines in nearly all primary health care centres around the country. METHODS Data from national registries, epidemiological studies and questionnaires were used to measure whether the goals had been reached. RESULTS The prevalence of COPD remained unchanged. Smoking decreased in males from 30% to 26% (p<0.001) and in females from 20% to 17% (p<0.001). Significant improvements in the quality of spirometry were obtained. Hospitalisation decreased by 39.7% (p<0.001). COPD costs were 88% lower than had been anticipated from earlier investigations. No increase in COPD mortality was observed. CONCLUSIONS In combination with other efforts, the Finnish 10-year COPD Programme had significant positive consequences: no further increases in COPD prevalence, reduced smoking prevalence, improved quality of diagnosis, and reduction in COPD-related hospitalisations.

No increase in the prevalence of COPD in two decades

Relevant information on the prevalence of chronic obstructive pulmonary disease (COPD) and its trends is scarce. In the present study, we compare the prevalence rates and potential determinants of COPD in two national population samples that were surveyed 20 yrs apart. In 1978–1980, a sample of 8,000 people was surveyed; subjects were representative of the Finnish population and were aged ≥30 yrs. Among those aged 30–74 yrs, acceptable spirometry was obtained from 6,364 (87%) subjects. In a similar survey conducted in 2000–2001, comparable spirometry was obtained from 5,495 (80%) participants. Airway obstruction was defined as forced expiratory volume in 1 s (FEV1)/forced vital capacity below the lower limit of normal and staged for severity on the basis of FEV1 % predicted. The age-adjusted prevalence rates of obstruction (stages I–IV) were rather similar in both surveys in males (4.7 versus 4.3%; p = 0.25), but were almost significantly higher in females in the later survey (2.2 versus 3.1%; p = 0.06). The rates of COPD stage II or higher were 3.9% in 1978–1980, and 3.6% in 2000–2001 (p = 0.36) for males, and 1.4 and 1.5% (p = 0.93), respectively, for females. In conclusion, no significant difference was found in the prevalence of COPD stages II–IV between similar population based surveys performed 20 yrs apart. Since COPD is mostly mild or moderate there is a strong case for early prevention.

COPD, chronic bronchitis and capacity for day-to-day activities: Negative impact of illness on the health-related quality of life:

The aim of this study was to investigate the negative impact of illness on health-related quality of life (HRQoL) of people with chronic obstructive pulmonary disease (COPD) or chronic bronchitis. The study population consisted of the participants (N = 8028) of a health examination survey conducted in Finland. The sample in the present substudy was composed of 4718 participants who had complete information about spirometry. Variables age, gender, body mass index (BMI), illnesses, smoking in lifetime, education, FEV1% and incomes were entered in blockwise bivariate regression analysis to examine the relationships between capability for day-to-day activities (physical, psychological and social functioning) of those with COPD. Also, COPD (n = 277) and chronic bronchitis (n = 630) were compared with the general population (n = 3817). Study results showed that women with COPD had worse HRQoL than men, regarding the activities in daily living (ADL; odds ratio [OR] 2.63, 95% confidence interval [Cl] 1.15—5.99), instrumental activities of daily living (IADL; OR 4.23, 95% Cl 1.92—9.29) and exercise (OR 2.66, 95% Cl 1.21—5.84). Compared with the general population, people with chronic bronchitis were associated with poor ADL, IADL and exercise, (OR 1.58, 95% Cl 1.32— 1.92). Those with COPD, had difficulties managing in ADL (OR 4.02, 95% Cl 2.98—5.44), IADL (OR 3.27, 95% Cl 2.43—4.39), exercise (OR 3.35, 95% Cl 2.47 to 4.53). In this representative population-based sample, COPD and chronic bronchitis mean a significantly poor capability in physical functioning. People with chronic bronchitis experienced their daily life to be worse compared with the general population. Reductions in physical functioning for women and especially with COPD were also noteworthy.

Lung function and respiratory diseases in people with psychosis: population-based study.

BACKGROUND There is little information on lung function and respiratory diseases in people with psychosis. AIMS To compare the respiratory health of people with psychosis with that of the general population. METHOD In a nationally representative sample of 8028 adult Finns, lung function was measured by spirometry. Information on respiratory diseases and symptoms was collected. Smoking was quantified with serum cotinine levels. Psychotic disorders were diagnosed utilising the Structured Clinical Interview for DSM-IV (SCID-I) and medical records. RESULTS Participants with schizophrenia and other non-affective psychoses had significantly lower lung function values compared with the general population, and the association remained significant for schizophrenia after adjustment for smoking and other potential confounders. Schizophrenia was associated with increased odds of pneumonia (odds ratio (OR) = 4.9), chronic obstructive pulmonary disease (COPD, OR = 4.2) and chronic bronchitis (OR = 3.8); and with high cotinine levels. CONCLUSIONS Schizophrenia is associated with impaired lung function and increased risk for pneumonia, COPD and chronic bronchitis.

Enhanced tuberculosis outbreak investigation using whole genome sequencing and IGRA

Whole genome sequencing (WGS) is a new powerful technology for characterisation of bacterial genomes and has been used successfully to investigate Mycobacterium tuberculosis isolates associated with tuberculosis (TB) outbreaks and to elucidate mutations conferring drug resistance [1–6]. Enhanced contact investigation and improved diagnosis and treatment of latent TB infection (LTBI) are an important strategy for TB control and elimination [7–10]. TB outbreak investigation can be enhanced by using whole genome sequencing, IGRA and social network analysis http://ow.ly/AzxfH